IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE APPLICATION FOR APPOINTMENT OF ADMINISTRATOR AD LITEM FOR CAUSE OF ACTION ONLY PART 2 PROBATE DIVISION FILE N0. T.C.A. § 30-1-109 IN THE MATTER OF THE ESTATE OF DECEDENT ITEM 1. APPLICANT. _____________________________________________________________________________________________________, requests the Court to appoint Applicant as Administrator ad litem of this estate for the limited purpose of a cause of action. ITEM 2. AVERMENTS. Applicant would show that Decedent died on _________________ at the age of ______ at ____________________________. Date City & State Decedent's residence at time of death was: ______________________________________________, _______________________________, ______________________ Street and Number City State Zip Code Applicant’s relationship to Decedent is ______________________________________________________________________ For legal action against___________________________________________________________________________________ _____________________________________________________________________________________ Applicant avers: these facts are true to the best knowledge, information, and belief of Applicant; no person is currently serving as administrator or executor for this estate; Applicant is aware of no person interested in the estate or willing to serve as administrator; Applicant is ready, willing, and qualified to serve as administrator ad litem according to law; the Administrator ad litem’s sole duty and function will be to provide a nominal party for a legal cause of action; and where it becomes necessary for Applicant to take control and custody of property or assets of this estate, Applicant shall execute a bond with good security before taking control and custody of such property or assets. ITEM 3. PREMISES CONSIDERED, APPLICANT PRAYS: 1. That facts have been shown herein, or will be made known by the testimony or affidavit of an interested person, to support the appointment of a limited administrator. 2. That Applicant be appointed administrator ad litem of this estate pursuant to T.C.A. § 30-1-109. 3. That the CLERK & MASTER qualify Applicant and issue Letters of Administration for Cause of Action Only. _______________________________________ Applicant’s Address ________________________________________ ____________________________________________ Applicant Signature ________________________________________ STATE OF TENNESSEE CHANCERY COURT OF HAMILTON COUNTY S. LEE AKERS, CLERK & MASTER Sworn to and subscribed before me on ___________________ By__________________________________________ date Deputy Probate Clerk ___________________________________________ Attorneys for Applicant BY______________________________________________ BPR# __________________________________________ Address ___________________________________________ Telephone N0. Fax N0. Page 1 of 2 pages. APPLICATION FOR APPOINTMENT OF ADMINISTRATOR AD LITEM FOR CAUSE OF ACTION ONLY Form 074P, Rev. 2010.09.28 American LegalNet, Inc. www.FormsWorkFlow.com MASTER’S ORDER PURSUANT TO T.C.A. § 16-16-201 From an examination of Applicant and witnesses under oath it appears the facts stated in the Application are true, and that after proper qualification and payment of costs and pursuant to T.C.A. § 16-16-201 letters of limited administration for an administrator ad litem are to be issued for cause of action only to: ____________________________________________________________________________________ Court costs are paid. No further reports are required by the COURT. NO YES If yes, this estate shall remain open for a period of 5-YEAR CAUSE OF ACTION? five (5) years after which it shall be closed unless requested by Administrator ad litem. Additional letters shall be issued as necessary upon payment of additional costs. This ____ day of ___________________________, 20____. ____________________________________ S. LEE AKERS, CLERK & MASTER Page 2 of 2 pages. APPLICATION FOR APPOINTMENT OF ADMINISTRATOR AD LITEM FOR CAUSE OF ACTION ONLY Form 074P, Rev. 2010.09.28 American LegalNet, Inc. www.FormsWorkFlow.com